Sample: Certificate of Rabies Vaccination

Sample: Certificate of Rabies Vaccination Certificate Issue Date: ______/_____/______ mm

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OWNER / CUSTODIAN IDENTIFICATION (please print): Name:

Phone:

Address:

Email:

ANIMAL IDENTIFICATION: Species □ Dog □ Cat □ Other _____________

Sex □ Male □ Female □ Neutered

Age _____ years _____ months

Animal Name:

□ Microchip □ Tatoo #______________

Breed/Colour/Markings:

Primary-Care Veterinarian (if known): VACCINE HISTORY (check one):

□ □

First rabies vaccination for this animal Certificate presented: date of vaccination

____/____/____ mm

□

Owner reported: date of vaccination

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____/____/____ mm

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VACCINE INFORMATION: Name: Lot:

□ 1 year □ 3 years Serial No:

Date of vaccination: ______/____/_____ mm

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Date of Revaccination: ______/____/_____ mm

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Vaccinate Administered By:

□ Veterinarian □ Auxiliary under supervision of veterinarian Rabies tag issued: #

INFORMATION: Location where animal was immunized (building, address, city):

Veterinarian name (print): ___________________________________________________ Signature: ________________________________________

Date: ____ / ____ / _____ mm

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